Team-Based Care: Who Do You Trust?

In this ongoing series on enabling team based care, we’re looking at how technology and human factors impact successful execution. As a framework, we’re applying the principles outlined by the Institute of Medicine for team-based care:

Shared Goals between both patient and the care team

Clear Roles and expectations for all stakeholders

Mutual Trust between all members of the team

Effective Communication between all stakeholders and across all care settings

Measurable Processes and Outcomes to track and improve performance

In a previous post, we discussed the importance of Clear Roles and Expectations for all stakeholders. How do we build trust between the members of the teams and ensure we trust the data?

At first glance, this can sound like a “soft” element of team-based care and certainly there is plenty to be said about team members respecting one another’s expertise in the context of care. In order for a team-based model to work, there has to be a relatively “flat” hierarchy that allows feedback to occur at all levels to create improvements.

A famous example is the story in support of the use of checklists to minimize infection rates related to heart catheter insertion. Dr. Peter Pronovost led the charge at Johns Hopkins Hospital to use checklists to ensure that all proper steps were followed each time a catheter was inserted, including a simple step: the physician washing his/her hands before the procedure. This is forgotten more than you might think and infections didn’t decrease until nurses were required to call out the physician if they didn’t see them washing their hands. If you know medical culture, it is rare for a nurse to be this empowered in a clinical setting, and this change in procedure was highly controversial. But when implemented, infection rates dropped, likely saving many lives.

A checklist is a relatively simple, but effective solution. Changing the hierarchical nature of healthcare delivery was much harder but was ultimately the key to making checklists far more effective.

In addition to open lines of communication among the members of the team, mutual trust occurs when a team is sharing information effectively. In our world of Kindles remembering what page you were on and Gmail synchronizing across multiple devices, this may seem painfully obvious, but this interconnectedness in healthcare is still easier said than done. Getting a variety of clinicians, social workers and other team members synchronized across multiple platforms and contexts is still a rarity and interoperability of systems is still a major challenge. This is why many believe that integrated delivery networks, or IDNs, represent the future of healthcare. IDNs like Geisinger, Baylor Scott and White and Kaiser Permanente are blends of hospitals and all the medical services necessary to maintain good health. Quite simply, it is easier to integrate all the players if everyone has the same systems and tools to work from. But it can also be done with existing teams as ACOs and Medicare Advantage plans have proven.

Let’s also remember the patient is part of the team as well. Patient portals that allow easy review and sharing of medical records, scheduling of appointments and questions for the care team and physician, are still a rarity as well. Part of the problem is usability, as many of the portals developed by EMR vendors were designed to fulfill Meaningful Use regulatory requirements and not delight end users. Another issue is the still fragmented nature of care for most who are not in IDNs or other integrated systems. Aggregating records across multiple portals is a clunky process for the patient and for many, more hassle than it’s worth. There is work on the horizon to use APIs, the extensions to computer systems that make many consumer apps possible, but until the patient is fully integrated into the team, we still have an incomplete solution.

Finally, trust is built on a solid foundation and in the care context, that foundation is data. Every member of the team has to trust that the information is timely and reliable. One of my mentors in public health used to coach me, “if you don’t know what you’re going to do with the data, don’t capture it.” Today, we have the ability and disk space to capture tremendous amounts of data and with greater processing power and advanced analytics, we can start to make insights that were unheard of even 10 years ago. We don’t always know what information will be relevant and incredible connections can be made in unlikely sources. The challenge is to turn that information into action by ensuring that data sources are aligned to the needs of the care team, by generating worklists and reporting that allow clinical teams to act in a timely fashion. Good data stewardship leads to clear and usable information, including appropriate workarounds for or simply not using unclear or unreliable datasets. This work means that everyone trusts the data and is willing to make clinical decisions based on it.

All of this does not have to come “from scratch,” and a number of healthcare organizations have retooled their operations to build that mutual trust, but it takes leadership, courage and strong partners.